Doctor’s Conclusion Outweighs Subjective Complaints

Case Name: Randall v. Metropolitan Life Insurance Company

Court: U.S.D.C for the Northern District of California

Date of Decision: February 6, 2017

Type of Claims: Short term disability, long term disability, and related health, dental, vision, and life insurance benefits.

Insurance Company: Metropolitan Life Insurance Company, aka MetLife.

Claimant’s Employer: Verizon Wireless

Claimant’s Occupation / Job Position: Facilities Network Engineer

Disabilities: Randall suffers from “a longstanding condition of chronic and severe mid back pain,” which has progressed over time. She has a history of breast cancer and has received diagnoses of anterolisthesis, cervical disc disease, osteoporosis, lupus, myofascial pain syndrome, anxiety, and depression. Randall now alleges that her back pain is exacerbated by sitting, standing, reaching, or keyboarding and that her pain, fatigue, and impaired concentration due to pain medication make it impossible for her to perform the essential functions of her job.

Definition of Disability Under the STD Plan:  Randall’s plan provided for Short Term Disability benefits for up to 26 weeks if she was found to be totally disabled. A “Total Disability” is defined under the plan as follows:

You are considered totally disabled under the Plan for purposes of [Short-Term Disability] benefits if, as a result of illness, injury or pregnancy, MetLife determines that you meet all of these conditions:
• You are absent from work for at least 8 full consecutive calendar days beginning with and including your first day absent from work because you are unable to perform for any Employer the Essential Functions of Your Occupation1 for which you are qualified by training, education or experience; and
• You have provided to MetLife objective medical evidence that sufficiently evidences, as determined by MetLife, that you cannot perform the Essential Functions of Your Occupation for which you are qualified by training, education or experience for any Employer. Your ability to get to and from the work place is not considered when determining whether you cannot perform the Essential Functions of Your Occupation if driving is not an Essential Function of Your Occupation . . .
• You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and
• You are unable to earn more than 80% of your pre-disability earnings at Your Occupation; and
• You are not engaged in any job/occupation, including self-employment, during the [Short-Term Disability] application process or while you are receiving [Short-Term Disability] benefits; and
• All information or documents to be considered has been received during the Initial Administration Period of your . . . claim.

Other Important Provisions: The Plan stated that Randall was “responsible for proving [her] disability claim.” Id. It instructed that she “must return a signed authorization form to MetLife allowing [her] Physician(s) to release objective medical evidence to substantiate [her] condition and ongoing treatment, as determined by MetLife,” and that benefits would automatically “be denied if [she or her] doctor or qualified practitioner fails to provide objective medical evidence in support of [her] claim within the time period specified by MetLife.” Id. The Plan specifically stated that “[a] physician’s note stating” that Randall “should not work is not objective medical evidence sufficient to prove [her] claim.”

The Plan specifically stated that “[a] physician’s note stating” that Randall “should not work is not objective medical evidence sufficient to prove [her] claim.”

The Plan provided some guidance as to objective medical evidence:

Objective medical evidence is necessary to clinically substantiate your condition and includes, but is not limited to:
• A diagnosis of your medical condition.
• Objective findings such as test results, X rays or operative notes supporting your claim for benefits.
• Any other information related to your individual circumstances that MetLife determines is necessary to decide whether your claim should be approved or denied.
• You and/or your Physician(s) may be required to provide additional information to substantiate ongoing treatment and/or evidence to support your continuing claim for short-term disability benefits. The costs associated with providing this information are your responsibility.

Definition of Disability Under the LTD Plan: The LTD Plan’s summary plan description (“SPD”) explains that “You will be eligible for LTD [Long Term Disability] benefits if you are continuously disabled and unable to return to work after receiving [Short-Term Disability] benefits for 26-weeks—provided you are certified as disabled under the LTD benefit component of the Managed Disability Plan and meet all other requirements detailed below.” The relevant sections of the Plan define LTD as follows:

You are considered disabled if MetLife determines that you have experienced, on or after the effective date of your LTD coverage under the LTD benefit component of the Managed Disability Plan, a significant change in your physical or mental condition as a result of accidental injury, sickness, mental illness, substance abuse or pregnancy.

Under the LTD benefit component of the Managed Disability Plan, an employee is considered to be “disabled” when the employee is absent from work because of an impairment for which there is sufficient objective medical evidence that supports:

For the first 24 months beginning with the LTD Effective Date:
• The employee cannot perform the Essential Functions of his or her job at Verizon Wireless.
• The employee cannot perform the Essential Functions of his or her occupation for which he or she is qualified by training, education or experience for any Employer.
For the period after the first 24 months beginning with the LTD Effective Date:
• The employee cannot perform the Essential Functions of any occupation for which he or she is qualified by training, education, or experience for any Employer.

During the period of disability, the employee must:
• Be receiving Appropriate Care and Treatment and complying with the requirements of such treatment;
• For LTD benefits, during the qualifying period and the next 24 months of sickness or accidental injury, the employee must not be able to earn more than 80% of the employee’s pre-disability earnings at the employee’s own occupation for any employer in the employee’s local economy. After the expiration of the qualifying period and the next 24 months, the employee must not be able to earn more than 60% of the employee’s pre-disability earnings from any employer in the employer’s local economy at any Gainful Occupation for which the employee is reasonably qualified taking into account the employee’s training, education and experience.

The LTD Plan also speaks to “Disability Due to Mental or Nervous Disorders or Diseases, Neuromusculoskeletal and Soft Tissue Disorders, Chronic Fatigue Syndrome and Related Conditions.” The Plan limits benefits for disability caused by mental or nervous disorders or neuromusculoskeletal and soft tissue disorders to a maximum of 24 months.

Randall’s plan also indicates, however, that the “certificate of insurance” governs the determination of her Long Term Disability benefits. The certificate of insurance states:

Disabled or Disability means that, due to Sickness or as a direct result of an accidental injury:
• You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and
• You are unable to earn:
• During the Elimination Period and the next 24 months of Sickness or accidental injury, more than 80% of Your Predisability Earnings at Your Own Occupation from any employer in Your Local Economy.

Benefits Paid? MetLife approved Short Term Disability benefits for Randall for the period between April 15, 2013, through May 6, 2013, but communicated to Randall on June 15, 2013, that benefits would not be approved beginning May 7, 2013.

Issues: The Court determined whether Randall “was entitled to benefits based on the evidence in the administrative record and ‘other evidence as might be admissible… .”

Holdings: ”The Court concludes that Randall has failed to prove by a preponderance of the evidence that she was disabled from May 7, 2013, onward and therefore that MetLife erred in denying her benefits.”

Noteworthy court comments: “While it is clear that Randall was diagnosed with several conditions and was experiencing pain, she has not proven that she was disabled and unable to perform the essential functions of her job.”
…
“Randall argues, in essence, that her consistent reports of pain and resulting diagnoses should be sufficient to establish by a preponderance of the evidence that she was disabled. Her consistent reports of subjective pain are not sufficient to find disability in the face of her doctors’ uniform conclusions that she should return to work.”